Transmyocardial laser revascularization for management of refractory angina
- Roger J Laham, MD
Roger J Laham, MD
- Associate Professor of Medicine
- Harvard Medical School
- Michael Simons, MD
Michael Simons, MD
- Robert W Berliner Professor of Medicine
- Yale University School of Medicine
- Section Editors
- Gabriel S Aldea, MD
Gabriel S Aldea, MD
- Section Editor — Cardiac Surgery
- Professor of Surgery
- University of Washington
- Edward Verrier, MD
Edward Verrier, MD
- Section Editor — Cardiac Surgery
- Professor of Surgery
- University of Washington School of Medicine
- Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Coronary Heart Disease; Myopericardial Disease
- Professor of Medicine
- Mayo Clinic College of Medicine
Despite the increasing success of conventional medical therapeutic approaches and the continued development and improvement of mechanical revascularization approaches (eg, drug-eluting stents), a significant number of patients with ischemic heart disease and angina pectoris cannot be successfully managed. (See "Stable ischemic heart disease: Overview of care" and "Stable ischemic heart disease: Indications for revascularization".)
In addition, a substantial proportion of patients undergoing percutaneous coronary intervention or coronary artery bypass surgery do not achieve complete revascularization and, despite maximal medical therapy, many of these patients continue to experience residual anginal symptoms or myocardial ischemia requiring hospitalization. The outcome with medical therapy is poor and one study of 59 such patients found that the one-year rate of myocardial infarction or death was 25.5 and 17 percent, respectively .
There are several novel therapeutic strategies that are currently being evaluated for treating patients with refractory angina . In 2002, a report from the European Society of Cardiology reviewed these strategies, including transmyocardial and percutaneous laser revascularization, and summarized the strength of the evidence supporting their use (table 1) .
The role of transmyocardial laser revascularization will be found here. Other modalities, including medical therapies such as antagonism of endothelin-1 and chelation, and invasive modalities such as promotion of angiogenesis, spinal chord stimulation, and external balloon counterpulsation are discussed elsewhere. (See "Therapeutic angiogenesis for management of refractory angina" and "New therapies for angina pectoris".)
Transmyocardial laser revascularization (TMLR) is a technique that uses laser ablation to create transmural channels in the ischemic myocardium in order to restore myocardial perfusion. It shows promise in patients who have angina that is refractory to medical therapy and who are not candidates for surgery or angioplasty. It has also been used as an adjunctive therapy with minimally invasive coronary artery bypass graft surgery to achieve more complete revascularization . Animal studies have shown that TMLR reduces infarct size and preserves myocardial function after an infarction . (See "Off-pump and minimally invasive direct coronary artery bypass graft surgery: Outcomes".) However, despite United States Food and Drug Administration (FDA) approval of some of the laser devices for treatment of intractable angina, these techniques are in the early stages of their development; while they offer much promise, there is substantial risk associated with their use.
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